Pharmacogenetic approaches in the treatment of alcohol use disorders: addressing clinical utility and implementation thresholds

Four Actionable Bottlenecks and Potential Solutions to Translating Psychiatric Genetics Research: An Expert Review

BACKGROUND

Psychiatric genetics has had limited success in translational efforts. A thorough understanding of the present state of translation in this field will be useful in the facilitation and assessment of future translational progress.

PURPOSE

A narrative literature review was conducted. Combinations of 3 groups of terms were searched in EBSCOhost, Google Scholar, and PubMed. The review occurred in multiple steps, including abstract collection, inclusion/exclusion criteria review, coding, and analysis of included papers.

RESULTS

One hundred and fourteen articles were analyzed for the narrative review. Across those, 4 bottlenecks were noted that, if addressed, may provide insights and help improve and increase translation in the field of psychiatric genetics. These 4 bottlenecks are emphasizing linear translational frameworks, relying on molecular genomic findings, prioritizing certain psychiatric disorders, and publishing more reviews than experiments.

CONCLUSIONS

These entwined bottlenecks are examined with one another. Awareness of these bottlenecks can inform stakeholders who work to translate and/or utilize psychiatric genetic information. Potential solutions include utilizing nonlinear translational frameworks as well as a wider array of psychiatric genetic information (e.g., family history and gene-environment interplay) in this area of research, expanding which psychiatric disorders are considered for translation, and when possible, conducting original research. Researchers are urged to consider how their research is translational in the context of the frameworks, genetic information, and psychiatric disorders discussed in this review. At a broader level, these efforts should be supported with translational efforts in funding and policy shifts.

Metabolomics biomarkers to predict acamprosate treatment response in alcohol-dependent subjects

Precision medicine for alcohol use disorder (AUD) allows optimal treatment of the right patient with the right drug at the right time. Here, we generated multivariable models incorporating clinical information and serum metabolite levels to predict acamprosate treatment response. The sample of 120 patients was randomly split into a training set (n = 80) and test set (n = 40) five independent times. Treatment response was defined as complete abstinence (no alcohol consumption during 3 months of acamprosate treatment) while nonresponse was defined as any alcohol consumption during this period. In each of the five training sets, we built a predictive model using a least absolute shrinkage and section operator (LASSO) penalized selection method and then evaluated the predictive performance of each model in the corresponding test set. The models predicted acamprosate treatment response with a mean sensitivity and specificity in the test sets of 0.83 and 0.31, respectively, suggesting our model performed well at predicting responders, but not non-responders (i.e. many non-responders were predicted to respond). Studies with larger sample sizes and additional biomarkers will expand the clinical utility of predictive algorithms for pharmaceutical response in AUD.

Primary Care Providers' Interest in Using a Genetic Test to Guide Alcohol Use Disorder Treatment

BACKGROUND

Efforts to identify genetic moderators of pharmacotherapy response have generated interest in clinical applications of pharmacogenetic tests in alcohol use disorder (AUD) treatment. To date, no research on providers' interest in using pharmacogenetic tests in the context of AUD treatment has been reported. We conducted qualitative interviews with primary care providers from 5 clinics in the Veterans Health Administration (VA) to assess their interest in using a hypothetical genetic test to inform treatment of AUD with pharmacotherapy.

METHODS

Key contacts were used to recruit 24 providers from 5 primary care clinics associated with a single large VA medical facility. Participants completed 30-minute in-person semi-structured interviews focused on barriers and facilitators to provision of pharmacotherapy for AUD. Interviews included a hypothetical scenario regarding the availability of a genetic test to inform AUD pharmacotherapy provision and/or selection. Provider responses to the hypothetical scenario were recorded, transcribed and analyzed qualitatively using inductive content analysis. Data were independently coded by three investigators, and themes were identified via consensus.

RESULTS

Participants were generally interested in a genetic test to aid in AUD treatment planning. Five common themes were identified, including: perceived benefits of a pharmacogenetic test (e.g., aiding with therapeutic choice, positively impacting patient motivation for and engagement with AUD treatment), perceived drawbacks (e.g., limiting potential benefits of pharmacotherapy by reducing the target population for its receipt, adverse impacts of "negative" results), caveats to clinical utility (e.g., utility would depend on prognostic accuracy and/or medication characteristics), uncertainty as to whether such a test would impact clinical decision-making, and pragmatic barriers to use (costs and other resources, such as laboratory facilities).

CONCLUSIONS

Primary care providers in this study generally believed a genetic test to aid in AUD treatment planning would be useful, due to its potential to hone treatment choice as well as to influence patient motivation and adherence to treatment. However, providers acknowledged that a test's utility would depend on the strength of its prognostic characteristics, its other benefits relative to standard care, and lack of pragmatic barriers.